Provider Demographics
NPI:1710084652
Name:LEWISVILLE DRUG COMPANY INC
Entity Type:Organization
Organization Name:LEWISVILLE DRUG COMPANY INC
Other - Org Name:LEWISVILLE DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:VANCE
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:336-946-0220
Mailing Address - Street 1:6715 SHALLOWFORD RD
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-9847
Mailing Address - Country:US
Mailing Address - Phone:336-946-0220
Mailing Address - Fax:336-946-0199
Practice Address - Street 1:6715 SHALLOWFORD RD
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9847
Practice Address - Country:US
Practice Address - Phone:336-946-0220
Practice Address - Fax:336-946-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
NC090193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2067979OtherPK
NC0347256Medicaid
NC0347256Medicaid